Pathophysiology Dislodgement of a blood clot: Lower
Extremities: 65% to 90% Pelvic venous system Renal venous system
Upper Extremity Right Heart
Slide 4
Risk Factors for PE and DVT Immobilization Surgery within the
last 3 months Stroke History of venous thromboembolism Malignancy
Preexisting respiratory disease Chronic Heart Disease Age >60
Surgery requiring >30mins of anesthesia Recent travel (past
2weeks, >4 hours) Varicose veins Superficial vein thrombosis
Central VV catheter/port/pacemaker Additional RF in Women: Obesity
BMI >/=29 Heavy smoking (>25cigs/day) Hypertension
Pregnancy
Slide 5
Wells Criteria Clinical Signs and Symptoms of DVT? (Calf
tenderness, swelling >3cm, errythema, pitting edema affected leg
only) +3 PE Is #1 Diagnosis, or Equally Likely+3 Heart Rate >
100+1.5 Immobilization at least 3 days, or Surgery in the Previous
4 weeks +1.5 Previous, objectively diagnosed PE or DVT?+1.5
Hemoptysis+1 Malignancy w/ Rx within 6 mo, or palliative?+1 >6:
High Risk 2 to 6:Moderate Risk 2 or less:Low Adapted with
permission from Wells PS, Anderson DR, Rodger M, Ginsberg JS,
Kearon C, Gent M, et al. Derivation of a simple clinical model to
categorize patients probability of pulmonary embolism: increasing
the models utility with the SimpliRED d-dimer. Thromb Haemost
2000;83:416-20.
Slide 6
P.E. and Malignancy A Presenting sign in: Pancreatic cancer
Prostate cancer Late sign in: Breast cancer Lung cancer Uterine
cancer Brain cancer
Slide 7
Symptoms of P.E. Dyspnea Pleuritic pain Cough Hemoptysis (blood
tinged/streaked/ pure blood)
Slide 8
Signs of P.E. Tachypnea Rales Tachycardia Hypoxia S4
Accentuated pulmonic component of S2 Fever: T 90 associated with
adverse clinical outcomes (death, CPR, mechanical vent, pressure
support, thrombolysis, embolectomy)
Slide 14
Lab Findings in P.E. (Troponin) Troponin High in 30-50% of pts
with mod to large PE Prognostic value if combined pro-NT BNP Trop I
>0.07 + NT-proBNP >600 = high 40 day mortality
Slide 15
Lab Findings in P.E. (D-dimer) D-dimer: Degredation product of
fibrin >500 is abnormal Sensitivity: High, 95% of PE pts will be
positive Specificity: Low Negative Predictive Value: Excellent
Slide 16
Slide 17
S1Q3T3!!!
Slide 18
RAD Right Atrial Enlargement
Slide 19
Lab Findings in P.E. (contd) EKG 2 Most Common finding on EKG:
Nonspecific ST-segment and T-wave changes Sinus Tachycardia
Historical abnormality suggestive of PE S1Q3T3 Right ventricular
strain New incomplete RBBB
Slide 20
Radiologic Findings in P.E.
Slide 21
GOLD STANDARD IN DIAGNOSING PULMONARY EMBOLISM? PULMONARY
ANGIOGRAM
Slide 22
Radiology Findings in P.E. (contd) CXR: Normal Atelectasis
and/or pulmonary parenchymal abnormality Pleural Effusion
Cardiomegally
Slide 23
Whats This??? Hamptons Hump
Slide 24
How About This??? Westermark's Sign: an abrupt tapering of a
vessel caused by pulmonary thromboembolic obstruction. This CXR
shows enlargement of the left hilum accompanied by left lung
hyperlucency, indicating oligemia (Westermark's sign).
Slide 25
Radiology Findings in P.E. (contd) V/Q Scan: Results: High,
Intermediate, Low Probability Best if combined with Clinical
Probability (PIOPED study): High Clinical Prob + High Prob VQ= 95%
likelihood of having a P.E. Low Clinical Prob + Low Prob VQ= 4%
likelihood of having a P.E.
Slide 26
Radiology Findings in P.E. (contd) Lower Extremity Ultrasounds
If DVT found then treatment is same if patient has a P.E.
Disadvantage: If negative, patients with PE may be missed If false
positive (3%), unnecessary intervention
Slide 27
Radiology Findings in P.E. (contd) CT Pulmonary Angiography
(CT-PA) Widely used Institution dependent Sensitivity (83%)
Specificity (96%): if negative, very low likelihood that pt has
P.E.
Slide 28
Radiology Findings in P.E. (contd) Pulmonary Angiogram Gold
Standard Not easily accessible Radiologist dependent
Slide 29
Radiology Findings in P.E. (contd) Echocardiogram Increased
Right Ventricle Size Decreased Right Ventricular Function Tricuspid
Regurgitation Rarely: RV thrombus Regional wall motion
abnormalities that spare the right ventricle apex (McConnells
Sign)
Slide 30
Hypercoagulability Work Up No consensus on who to test
Increased likelihood if: Age
Slide 31
Hypercoagulability Work Up Protein C/S deficiency Factor V
leiden deficiency AntiThrombin III deficiency Prothrombin 20210
mutation Antiphospholipid antibody High Homocysteine
Slide 32
Most Common Cause of Congenital Hypercoagulablity Protein C
resistance d/t Factor V leiden mutation
Anticoagulation Start during resuscitation phase itself If
suspicion high, start emperic anticoagulation Evaluate patient for
absolute contraindication (i.e.: active bleeding)
Slide 35
Anticoagulation (contd) HEPARIN: Lovenox: if hemodynamically
stable, no renal function 1mg/kg BID OR 1.5mg/kg QDay Heparin gtt:
if hypotension, renal failure 80units/kg bolus then 18units/kg
infusion Goal PTT1.5 to 2.5 times the upper limit of normal
COUMADIN: Start once acute anticoagulation achieved Start with 5mg
PO qday OR 10mg PO q day If start with 10mg then achieve
therapeutic INR 1.4 days sooner Complications and morbidity no
different in 5mg or 10mg start Goal INR 2 to 3
Slide 36
Slide 37
Slide 38
Duration of Anticoagulation for DVT or PE*
EventDurationStrength of Recommendation First Time event of
Reversible cause (surgery/trauma) At least 3 mosA First episode of
idiopathic VTE At least 6 mosA Recurrent idiopathic VTE or
continuing risk factor (e.g., thrombophilia, cancer) At least 12
mosB Symptomatic isolated calf-vein thrombosis 6 to 12 weeksA *From
American College of Chest Physicians
Slide 39
Thrombolysis Considered once P.E. diagnosed If chosen, hold
anticoagulation during thrombolysis infusion, then resumed
Associated with higher incidence of major hemorrhage Indications:
persistent hypotension, severe hypoxemia, large perfusion defecs,
right ventricular dysfunction, free floating right ventricular
thrombus, paten foramen ovale Activase or streptokinase
Slide 40
IVC Filter Indication: Absolute contraindication to
anticoagulation (i.e. active bleeding) Recurrent PE during adequate
anticoagulation Complication of anticoagulation (severe bleeding)
Also: Pts with poor cardiopulmonary reserve Recurrent P.E. will be
fatal Patients who have had embolectomy Prophylaxis against P.E. in
select patients (malignancy)
Slide 41
Embolectomy Surgical or catheter Indication: Those who present
severe enough to warrant thrombolysis In those where thrombolysis
is contraindicated or fails
